1. Field of the Invention
This invention relates to toothbrushing, particularly in the prevention and treatment of periodontal disease. More specifically, this invention is directed to improving access to the gingival sulcus.
Much as through nature, hard structures in an aquatic environment become colonized by numerous living forms specifically adapted for growth upon submerged surfaces gingival sulcus. The teeth provide a natural habitat, or ecological niche, for microbiological life that is uniquely adapted for growth upon hard surfaces in the fluid environment of the mouth and gingival crevices. Certain types of microorganisms can attached themselves to the teeth, proliferate and invade the crevice between the gum margins and teeth, and over a period of years progressively coat the root surfaces. There is evidence that the bacteria that populate the teeth of persons with excellent periodontal health differ markedly from those that inhabit the surfaces adjacent to diseased tissues. Associated with disease are populations that differ with respect to the types of cells, their organization, and also their behavior. For example, disease is associated with flexing masses of spirochetes, gliding rods, amoebae, etc. The toxins produced and circulated by these microorganisms are not tolerated by the periodontal tissues, and as a result, they become inflamed recede, and gradually separate away from the infected root surfaces. Therefore, the primary goal of periodontal thereapy must be the elimination of bacterial populations that release toxic by-products in gingival crevices and pockets, in other words, control of creviculoradicular infection.
Treatment has traditionally been primarily centered in the dental office. In one advanced method of treatment, at each visit of the patient to his dentist, a specimen is removed from selected root surfaces and examined for the prevalance of white blood cells and motile bacteria. All probable spaces are then irrigated or treated with an antiseptic solution, e.g., a 1% solution of chloramine-T. Then the root surfaces are carefully debrided with scalers, files, and other instruments to remove living and mineralized bacterial deposits. The scaling instruments are repeatedly passed through an antiseptic during the debridement procedures.
In addition to professional treatment in a dentist's office, it is beneficial for the patient to administer self-treatment on a daily basis. Such self-treatment usually comprises in addition to toothbrushing, dental flossing, brushing interproximally and irrigation with various antiseptic or antibacterial solutions.
If there has been advanced loss of periodontal attachment (deep pocketing and bone resorption), it may be difficult to obtain adequate suppression of bacteria and white blood cells by office treatments and currently available homecare procedures alone. Therefore, patients may be advised to take an antibiotic, usually tetracycline HCl for two, possibly three weeks to suppress the bacteria in difficult-to-reach areas. Patients take 250 mg of tetracycline four times a day (q.i.d.) one hour before meals and at bedtime with water. If the microscopic examination reveals negative fields at the end of two weeks of therapy, the medication is discontinued. If the microscopic examination does not reveal negative fields, or if the case is very advanced, the antibiotic may be continued for another week, unless there is an acute problem, e.g., parietal abscess, the antibiotic is not prescribed before the roots have been scaled as described, and the patient has learned a home-care regimen appropriate for his needs. The antibiotic is not used again unless microscopic findings indicate that a pyogenic or potentially pyongenic population has reestablished itself.
During the initial stages of treatment patients are seen three to four times over an interval of six to eight weeks. During the follow-up maintenance period patients with advanced problems are examined clinically and microscopically every two or three months to minimize their risk of developing renewed bacterial activity on roots and in circumradicular succi. At each visit all patients receive antiseptic irrigations and scalings that are appropriate for the problem at hand.
The oral hygiene programs used by patients are not inflexible, as a number of variations can effectively reduce the germ life that forms on the surfaces of the teeth. For example, the careful application of various salts (sodium chloride, sodium bicarbonate, sodium recinoleate, sodium periodate, aluminum chlorate, magnesium sulface, zinc phenolsulfonate, etc.) can help to control bacterial activity on root surfaces and in circumradicular succi.
Patients are advised to irrigate, to brush and floss, or to use toothpicks whenever possible soon after eating, because food residues, particularly carbohydrates, contribute to the propagation of bacteria especially adapted for adhesion and growth upon tooth surfaces. Before retiring, or after the last meal or snack of the day, patients are advised to use measures along the following lines:
1. To floss if appropriate with floss or dental tape. This will help to cpen and clear some of the interdental spaces and surfaces. It will not clear concave surfaces, however.
2. To irrigate with water after flossing. Patients with advanced lesions may omit flossing and start with the irrigation. For severe lesions a warm brine solution is usually recommended during the early stages of treatment. Patients using electric irrigators such as the Water Pick (TM) should use lower pressures unless advised differently. Placement of the irrigator tips, some of wbich are custom-made, is demonstrated on special models, at chairside, and if necessary before a mirror over a sink.
3. After the irrigation the teeth may be treated with mixture of 3% hydrogen peroxide, salt (sodium chloride), and baking soda (sodium bicarbonate). One way to prepare the mixture follows: a bottle-capful of peroxide is poured into a tumbler or medicine cup; about 1/4 teaspoon of salt is added to the solution. The bristles of the toothbrush are moistened with the peroxide-saline solution and then dipped into baking soda. Some of the soda will cling to the bristles (as conventional toothbrushing with baking soda) and the bristles are then used to smear the mixture along the gum margins and into the spaces between the teeth. Typically, the teeth are not brushed at this time. Instead, the patient is urged to use the tip of a finely pointed stimulator (e.g. Butler 600) to wipe bacteria and pus from his root surfaces by inserting the point gently between the his gum margins and teeth and by moving it carefully along the tongue-side and cheek-side of the teeth. The procedure includes pressing the tip firmly into spaces between the teeth to squeeze out bacteria and pus from approximal root surfaces. A mirror with a good light source is usually necessary to enable one to watch this procedure carefully. After every tooth has been carefully encircled in this manner, the teeth are brushed with the soda-salt-peroxide mixture.
The patient then brushes, using a small brush with fine flexible bristles. The brush is held at about a 45.degree. angle towards the gingival margins and it is rapidly jiggled back and forth to distribute the antibacterial paste into the crevices between the teeth and gum margins (gingival crevices). For this purpose an electro-mechanical toothbrush can be very helpful. One that has a fast circular motion will help to spin the soda paste into gingival crevices and other difficult-to-reach sites. The electric toothbrush made by Water Pik works well for this purpose because of its circular motion. A toothpick held in a special handle, "Perio-Aid", may be used in areas where more positive action is needed. Various types of special brushes may be recommended for special situations. Patients need guidance from a dentist or a hygienist for proper use of these procedures.
After using the salt preparation, patients should rinse with water until all taste cf salt has disappeared. Patients on low-sodium diets can substitute magnesium sulfate (Epsom salt, MgSO.sub.4) for the sodium chloride and sodium bicarbonate. The taste is slightly bitter when first applied, but not objectionable. With magnesium sulfate the consistency of the paste will be somewhat granular. Glycerol, GlyOxide and other adjuvants may be tried. The efficacy of tbe agents and delivery system will be revealed by periodic microscopic examinations of specimens removed from the circumradicular spaces.
4. If root surfaces become sensitive after the gums receed, patients are advised to apply a few drops of fluoride gel (1.0% neutral or slightly acidulated sodium fluoride gel available on prescription) to the sensitive areas with a cotton swab, the stimulator, or a brush. The fluoride treatment is applied after the teeth have beer cleaned as described, and the mouth is not rinsed after the application. Sensitivity usually subsides within a few days. The gel can be reapplied if needed.
As can be seen, such a procedure is usually quite time-consuming, in the order of 35 minutes for each daily routine. This requires, in addition to a certain amount of personal will from the patient, at least an average intellectual capacity in order that he can comprehend all of the steps required. It would therefore be desirable to Irovide an arrangement which can be used to combine all of the above steps (with the exception of step 5) into one or two steps.